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Landro L. Wall Street Journal. March 5, 2008:D1.
This article reports on new policies and procedures adopted by hospitals to prevent errors in the use of high-alert medications, such as heparin.
Journal Article > Study
Wakefield DS, Wakefield BJ, Despins L, et al. Jt Comm J Qual Patient Saf. 2012;38:24-33.
Verbal orders, usually for medications, are commonly used in the inpatient setting despite being a recognized source of error. This survey of 40 hospitals found wide variation in hospital policies regarding verbal orders, with no uniform standard on which providers were allowed to give or receive verbal orders and varying approaches to documenting these orders. Although specific methods, such as read-backs, are endorsed for improving the reliability of verbal orders, few hospitals specifically mandated the use of these communication tools. A case of a misunderstood verbal order that led to a serious error is discussed in this AHRQ WebM&M commentary.
ISMP Medication Safety Alert! Acute Care Edition. November 1, 2018;23:1-5. November 15, 2018;23:1-5.
Errors in the administration of intravenous medications can result in patient harm. This set of articles discusses the results of a nationwide IV push medication survey. The first article reviews unsafe practices in care delivery as defined by inpatient clinicians. The second article recommends ways to improve practice such as assessment of current practices, use of prefilled syringes, and heightened attention to effective labeling.
Mix-ups between epidural analgesia and IV antibiotics in labor and delivery units continue to cause harm.
ISMP Medication Safety Alert! Acute Care Edition. October 4, 2018;23:1-4.
Increased urgency to prevent maternal mortality has uncovered various factors that diminish safety. This newsletter article reports on incidents involving the accidental misuse of epidural analgesia and intravenous antibiotics in labor and delivery care, describes contributing factors (e.g., health technology missteps, barcoding mistakes, and look-alike medications), and offers improvement strategies to mitigate harm.